The Gift That Keeps on Giving: Increasing Donation Rates by Offering Incentives

[Clark]

http://onlinelibrary.wiley.com/doi/10.1111/ajt.13850/full

Editorial
The Gift That Keeps on Giving: Increasing Donation Rates by Offering Incentives
D. S. Goldberg, J. D. Trotter
 DOI: 10.1111/ajt.13850
American Journal of Transplantation

Abstract
Updated data on the impact of Israeli organ donation laws suggest that opt-in donation systems that provide incentives may increase donation rates, but these data should be taken with some caution. See the article by Stoler et al on page 2639.
Across the globe, there is a shortage of donor organs for patients with end-stage organ disease. In most countries, organ donation is stagnant. Over the years, different approaches have been attempted with variable success. Most have focused on media appeals to encourage organ donation. A more direct means to try to improve organ donation would be to reward persons who either agree to donate (in the event of their brain death) or authorize donation by their next of kin. In Singapore, which has an “opt out” organ donation system (all citizens are considered eligible for donation unless they formally opt out of consideration), priority for transplant is given to those who have not opted out [1]. A different system was recently implemented in Israel, where citizens were rewarded for either registering as a donor or authorizing donation by their next of kin. Israel, like most countries, has an “opt in” donation system in which organ donation is not presumed and requires specific authorization by registration of the individual person (prior to brain death) or by next of kin. Specifically, the Israeli law provided two incentives: (i) Patients waitlisted for solid organ transplant who had previously registered as an organ donor ≥3 years before listing received higher transplant priority, and (ii) first-degree relatives of those who either donated an organ while alive or authorized donation by their next of kin were granted higher transplant priority. Stoler et al reviewed changes in organ donation before and after implementation of this novel national policy [2].
In this paper, the authors highlighted several important findings (2). First, rates of authorization by next of kin of potential donors increased from 45.0% (1998–2010) to 55.1% (2011–2015), with an all-time high of 60.2% in 2015. In addition, rates of authorization by next of kin of nonregistered potential donors increased from 42.2% (1998–2010) to 51.1% (2011–2015). Furthermore, in logistic regression models, the authors demonstrated a significant increase in the yearly trend in deceased donor authorization rates (p = 0.04). This indirectly demonstrates that incentives rewarding next of kin for authorizing donation were successful to some degree. Finally, rates of authorization by next of kin or registered donors decreased insignificantly from 91.3% (1998–2010) to 87.0% (2011–2015). The authors hypothesized that this decrease may reflect “fake” registrations by persons who registered to gain a listing advantage in the event they require a transplant while living and simultaneously instructed their family not to respect their wishes. Although plausible, this explanation is speculative.
These data are encouraging but must be taken with caution. First, this epidemiological study demonstrates only an association between passage of a law and donation rates, not cause and effect. Without a control group or a difference-in-differences analysis, the authors cannot definitively conclude that the policy led to changes in donation rates instead of changes in attitudes toward donation or in the population demographics. In addition, the policy changes occurred concurrently with a public awareness campaign about organ donation that may have changed donation rates. Second, although the authorization rates improved over time, the total number of donors was flat despite an increase in the population [2]. Consequently, novel donor initiatives may be successful without actually increasing the number of actual donors. In addition, the baseline donation rates in Israel are low, especially compared with those in many Western countries. Whether these incentives would yield similar results in more “organ-rich” countries is unclear. Although these interventions could be tested in targeted populations in the United States that have lower authorization rates but higher rates of end-stage organ disease (i.e. black and Hispanic groups) or in regions of lower donor registration, concerns exist about offering an incentive to only certain demographic or geographic populations [3]. The other finding that is potentially concerning regards the decreased rates of authorization by next of kin of registered donors. If the authors’ hypothesis is correct, then policy revisions are needed. An argument could be made, for example, that once a donor is registered, next of kin would not be able to reverse such a decision. This approach would not only honor patient autonomy but also prevent fake registrations. Independent of the results of this study, one needs to consider the ethical implications of reciprocity under the Israeli system. Although there is likely little opposition to awarding higher waitlist priority to someone who has registered as an organ donor, rewarding the next of kin of donors raises ethical questions. If a donor's next of kin has justified oppositions to being an organ donor, does that mean that person should be prioritized lower than someone whose relative is supportive of organ donation? This is an important consideration in a system that rewards donation decisions not only by an individual person but also by their first-degree relatives, especially in countries like the United States, which includes people of all religions and cultures, some of which are not supportive of organ donation (in Israel, nearly all citizens are Jewish, Arab Muslim, or Arab Christian). This also raises an ethical issue in which allocation priority is based on organ donation rather than medical need.
In conclusion, the novel donor incentive policy recently introduced in Israel was associated with some improvements in organ donation. Consequently, these initiatives could be considered in other countries with baseline low authorization rates but may not be successful in the United States.